Ocular complications associated with brucellosis in an endemic area

An Unusual Manifestation of Brucella-Associated Uveitis in a Young Male Patient

This is a unique case of retinoschisis as an ocular manifestation of brucellosis. A 38-year-old male presented with recurrent episodes of bilateral eye redness, predominately in his left eye. His visual acuity was not affected, and he did not report any other symptoms. On slit lamp examination, binocular Koeppe nodules of the iris and cells in the left anterior chamber were observed. Fundoscopy followed by meticulous multimodal imaging confirmed left inferior retinoschisis. The patient was diagnosed with panuveitis, and a series of laboratory examinations revealed positive anti-IgM Brucella antibodies. Ocular brucellosis can cause variable, atypical, and serious presentations, hence, early diagnosis is paramount to avoid complications.

Ocular Involvement of Brucellosis: A Pooled Analysis Study

AIM

Brucellosis may affect the eye to varying degrees. The aim of this study was to investigate the ocular involvement of brucellosis and highlight key points.

MATERIAL AND METHODS

Published literature in English language on the ocular involvement of brucellosis within last 30 years was evaluated. The PubMed international database was screened using certain keywords.

RESULTS

The study included 27 publications evaluating a total of 159 cases. The most common types of ocular involvement were uveitis (52.2%) and conjunctivitis (17.6%). Most cases had concomitant systemic brucellosis (27.7%), and the most commonly used diagnostic method was a serological test (92.4%). Of all the patients, 37.1% recovered with sequelae.

CONCLUSION

Brucellosis may cause a wide range of ophthalmic manifestations, and an overlooked or late diagnosis may also lead to the development of sequelae or loss of vision. A routine ophthalmologic examination should be performed in all patients with systemic brucellosis.

Ocular Lesions in Brucella Infection: A Review of the Literature

Ocular lesions due to Brucella infection are uncommon and easily overlooked in clinical management, but must be differentiated from non-infectious eye diseases and treated promptly to protect the patient's vision. We reviewed the relevant literature and identified 47 patients with ocular complications of Brucella infection. Among them, 28 showed ocular neuropathy, 15 presented with uveitis, and four patients displayed other ocular symptoms. Ocular symptoms accompanying Brucella infection require prompt diagnosis and treatment. The main methods of diagnosis are intraocular fluid tests and blood tests. Early diagnosis and treatment with suitable antibiotics are central to protecting the patient's vision. Notably, in terms of mechanism of injury, Brucella infection is chronic and cannot be eliminated by phagocytes, and can cause damage to the eye by inducing autoimmune reactions, antigen-antibody complex production, release of endogenous and exogenous toxins, and bacterial production of septic thrombi in the tissues. In this review, we summarize the ocular symptoms, diagnosis, treatment and prognosis of Brucella infection, and discuss the mechanisms of Brucella in ocular lesions, providing a reference for the diagnosis and treatment of Brucella ocular lesions.

A rare case of brucellosis with dermatomal pattern of cutaneous manifestation

Brucellosis is a systemic disease which may involve any organ or system of the body, and is listed in the differential diagnosis of many diseases. In spite of described cutaneous involvements, skin manifestations are not common in brucellosis, particularly papulonodular lesions with dermatomal patterns that may overlap with dermatomal skin lesions. This may prevent correct diagnosis and treatment in practice, harming patients’ health and leading to financial costs to the health system and patient. In this case, at first, due to left thigh and buttock skin lesions and dermatomal pattern, the patient was diagnosed with Herpes zoster infection. After medical treatment and no improvement of lesions, the patient was referred to the infectious clinic with low back pain; magnetic resonance imaging (ordered by a neurosurgeon) suggested infectious spondylodiscitis. At the infectious ward, brucellosis spondylitis was diagnosed and a biopsy was taken from dermatomal lesions. The patient’s follow-up after 1, 2, and 3 months revealed that treatment of brucellosis had led to healing of lesions. Surprisingly, the histopathological assessment of the biopsy suggested psoriasis vulgaris. This was a rare case of manifestation of cutaneous brucellosis which could not even be diagnosed by histopathological assessment.

Infectious optic neuropathies: a clinical update

Different forms of optic neuropathy causing visual impairment of varying severity have been reported in association with a wide variety of infectious agents. Proper clinical diagnosis of any of these infectious conditions is based on epidemiological data, history, systemic symptoms and signs, and the pattern of ocular findings. Diagnosis is confirmed by serologic testing and polymerase chain reaction in selected cases. Treatment of infectious optic neuropathies involves the use of specific anti-infectious drugs and corticosteroids to suppress the associated inflammatory reaction. The visual prognosis is generally good, but persistent severe vision loss with optic atrophy can occur. This review presents optic neuropathies caused by specific viral, bacterial, parasitic, and fungal diseases.

Bilateral sacroiliitis and uveitis comorbidity: brucellosis? Ankylosing spondylitis?

We present a rare case of a comorbidity of sacroiliitis and brucellosis infection. A 28-year-old woman received irregular medication due to ongoing backache and hip pain for 5 years. The patient presented to our hospital for evaluation of visual loss and was diagnosed with uveitis. Sacroiliac MRI was performed to investigate the inflammatory backache and hip pain, and the aetiology of the uveitis, revealing the presence of sacroiliitis. The patient's blood test results were as follows: positive brucellosis Rose Bengal test and positive tube agglutination test with a titre of 1/640. The patient was treated with doxycycline and rifampicin for 8 weeks for the brucellosis infection, and with acemetacin for the ankylosing spondylitis. The patient's back and hip pain decreased significantly 8 weeks later; however, the uveitis was not controlled by the treatment. Therefore, anti-tumour necrosis factor (infliximab) treatment was started.

Ocular involvement of brucellosis

A 29-year-old male diagnosed with brucellosis a week earlier was referred to the ophthalmology clinic with visual complaints. On examination, visual acuity was 20/25, he had conjunctival injection on slit lamp examination. There was also bilateral optic disk swelling plus retinal hyperemia (optic disc hyperemia and vascular tortuosity) and intraretinal hemorrhage on funduscopy. The patient was admitted and treated with cotrimoxazole, rifampin, doxycycline and prednisolone for 2 months. Ocular manifestations subsided gradually within 6 months after treatment. Brucellosis can affect the eye and lead to serious ocular complications. Early diagnosis and prompt treatment should be considered in endemic areas.

Brucellar uveitis: intraocular fluids and biopsy studies

BACKGROUND

Ocular brucellosis is usually diagnosed by clinical criteria and serological tests. Little is known with regard to the ocular immunology of brucellosis and the use of intraocular diagnostic tests. We report retrospectively the laboratory findings of patients with ocular involvement associated with brucellosis.

MATERIALS AND METHODS

Patients with uveitis with no evident etiologic diagnosis were evaluated at the Instituto de Medicina Tropical "Alexander von Humboldt" of the Universidad Peruana Cayetano Heredia and the Hospital Nacional Cayetano Heredia. Patients were tested for brucellosis, tuberculosis, syphilis, toxoplasmosis, toxocariasis, and human T-cell lymphotropic virus-1. Blood and intraocular fluid samples were examined. Patients with a diagnosis of brucellar uveitis were selected as cases and patients with a diagnosis of uveitis of other etiology were included as controls. The Goldmann-Witmer coefficient was determined.

RESULTS

Twelve patients with clinical and laboratory findings suggestive of brucellar uveitis were considered as cases. Seven patients with uveitis of other etiology were selected as controls. Four (33.3%) patients with ocular brucellosis had negative ocular agglutinations and eight (66.7%) had positive agglutinations. No control cases had positive agglutinations for Brucella melitensis. The sensitivity of the test was 66.7% and the specificity 100%. Only one patient had a positive culture for B. melitensis in subretinal fluid. The Goldmann-Witmer coefficient was calculated in six cases of brucellosis uveitis and five uveitis controls. It was highly positive in three patients with ocular brucellosis. Tissue samples showed lymphoplasmacytic infiltrates.

CONCLUSIONS

Intraocular serological tests could be used to support the diagnosis of ocular brucellosis.

A review of pediatric uveitis: Part I. Infectious causes and the masquerade syndromes

Uveitis is a manifestation of complex processes that can represent an infectious or a purely immune system modulated condition and may have grave effects on the eye. Much of the morbidity in these conditions is the result of the immune response to these stimuli. These infectious diseases may be successfully treated by addressing the inciting organism with recognized interventions. Treatment of the immune response to the organism often must be pursued simultaneously to minimize long-term complications caused by structural changes within the eye. Assisting the individual's immune response to eliminate the organism while minimizing the immune response's damaging effects remains a unique challenge drawing on both the science and the art of medicine. Several non-infectious conditions that are not autoimmune diseases may commonly masquerade as uveitis, leading to delays in appropriate treatment.

Periorbital and orbital infections

Practitioners frequently have the opportunity to manage the child for whom the chief complaint is a swollen eye. Some children have trivial or self-limited disorders, but others can have sight- or life-threatening problems. Noninfectious causes of the swollen eye include blunt trauma, tumor, local edema, and allergy. Infectious causes can be preseptal or orbital in origin. The differential diagnosis and management of these conditions are considered in this article.

Irreversible papillitis and ophthalmoparesis as a presenting manifestation of neurobrucellosis

A 35-year-old man presented with a meningeal syndrome and acute onset of visual blurring. Clinical investigations revealed bacterial meningitis with bilateral papillitis and ophthalmoparesis. Serum and cerebrospinal fluid serology confirmed the diagnosis of chronic active neurobrucellosis. Following therapy there was no improvement and he developed optic atrophy. Extensive literature review revealed, one case of bilateral irreversible papillitis resulting from neurobrucellosis. However no cases of neurobrucellosis have been reported with meningitis, irreversible papillitis and ophthalmoparesis. This case demonstrates that in endemic areas, acute meningitis is a potential manifestation of neurobrucellosis and that bilateral irreversible papillitis with ophthalmoparesis can be a potential serious complication.

Prevalence of Brucella antibodies in rural and suburban communities in three provinces of Turkey: Need for improved diagnosis and prevention

OBJECTIVE

To determine the seroprevalence of Brucella-specific antibodies in rural and suburban communities in different provinces of Anatolia.

METHOD

Cross-sectional seroepidemiological study on serum samples collected in communities in two relatively developed provinces in west Anatolia with an official low prevalence of brucellosis and in one province in southeast Anatolia with a high prevalence.

RESULT

The seroprevalence of brucellosis in the two provinces in the west Anatolia appears to be high and ranged from 2.9 to 8.5% in Rose Bengal test and from 0 to 5.6% in Wright serum agglutination test at a titer equal or higher than 1:100. The seroprevalence in communities in the province in southeast Anatolia was lower and this might well be attributed to vaccination of livestock in the year preceding the survey.

CONCLUSION

Adherence to traditional farming practices and lifestyle, and a preference for fresh dairy contribute to the high seroprevalence of brucellosis. Vaccination of livestock is of utmost importance and the consumption of fresh milk and dairy products prepared from unpasteurised milk should be halted. Better access to laboratory testing is needed for the confirmation and management of brucellosis.

Unusual presentation of brucellosis in a child: acute blindness

In brucellosis, visual impairment due to optic nerve involvement is rare, and acute onset visual loss is an unusual presenting feature. We report a 15-y-old girl who had pancytopenia and who was admitted to our hospital with acute onset of bilateral blindness and fever. There was no light perception, and anterior segment and fundus examination were normal in both eyes. No other abnormal neurological findings were detected. Increased latencies and decreased amplitudes were found in visual evoked potentials. Cranial MR and CT revealed no abnormality. Blood culture was found to be positive for Brucella melitensis. Anti-Brucella treatment and high-dose metil prednisolon were given. Pancytopenia completely resolved 5 d after anti-Brucella treatment, and at the end of the third month her complaints about impaired vision were resolved.

CONCLUSION

Brucellosis may present with uncommon symptoms in children. Physicians, particularly in areas where the disease is endemic, must consider this in differential diagnosis of a child with acute blindness and pancytopenia.

The eye in systemic infection

Bacterial, fungal, viral, and parasitic pathogens all cause systemic infection and can spread to the eye. Dissemination of pathogens via the bloodstream can lead to direct involvement of the eye. Visual loss is common in bacterial or fungal endophthalmitis, and toxoplasmosis is a major cause of ocular morbidity and poor vision after congenital or acquired infection. Some infections cause intraocular damage by indirect mechanisms (eg, HIV-mediated immunosuppression), leading to opportunistic infections such as cytomegalovirus infection, periocular nerve involvement due to leprosy, and hypersensitivity reactions in tuberculosis. Eye symptoms might indicate the outcome of an underlying infection, such as development of retinal ischaemia in severe malaria, which is associated with a poor prognosis. Successful outcome for patients with ocular infection depends on close collaboration between clinicians identifying and treating underlying disease, specialist ophthalmic review, and ophthalmic interventional skills (when needed).